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Omvoh — Medical Mutual

Ulcerative Colitis

Initial criteria

  • Patient age ≥ 18 years; AND
  • According to the prescriber, patient will receive three induction doses with Omvoh intravenous within 3 months of initiating therapy with Omvoh subcutaneous; AND
  • Patient meets ONE of the following (a or b): a) Patient had a trial of one systemic agent for ulcerative colitis; OR b) Patient has pouchitis AND has tried an antibiotic, probiotic, corticosteroid enema, or mesalamine enema; AND
  • Medication is prescribed by or in consultation with a gastroenterologist

Reauthorization criteria

  • Patient has been established on the requested drug for at least 6 months; AND
  • Patient meets at least ONE of the following: a) Beneficial clinical response when assessed by at least one objective measure; OR b) Improvement in at least one symptom compared with baseline (such as decreased pain, fatigue, stool frequency, and/or decreased rectal bleeding)

Approval duration

initial 6 months; reauth 1 year